Prenatal alcohol exposure is known to cause brain damage. Persons with brain damage resulting from drinking during pregnancy have developmental disabilities and related lifetime problems in school, employment, and independent functioning. Alcohol counseling offered as part of prenatal care has been shown to decrease drinking among pregnant women and the adverse consequences to their babies. Few prenatal care clinics are prepared to offer specialized alcohol treatment. An alternative strategy is to improve the efficacy of minimal counseling and referrals offered within obstetric care settings. In two decades of clinical trials, brief interventions have been shown to reduce drinking, improve health, and increase the rate of successful referrals to alcohol treatment. Motivational Interviewing has been shown in a pilot study to reduce drinking among high-risk pregnant women. The proposed project aims to replicate these findings with a larger sample to develop motivational strategies that can be implemented during early prenatal care in primary health care settings to decrease maternal and fetal risks due to drinking. A brief counseling approach will be tested in a randomized clinical trial. A sample of 300 at-risk drinkers receiving prenatal care will be assigned to one of three conditions prior to their referral for alcohol treatment: (1) Motivational Enhancement Therapy (MET); (2) a comparison group who will also receive MET, but 6 weeks later; or (3) Treatment- As-Usual, screening and advice to abstain. Maternal outcomes to be assessed include drinking and other drug use during subsequent pregnancy and postpartum, risk perception and motivation for change, alcohol treatment adherence, and psychological status. Infant psychomotor, physical, and cognitive development will also be assessed at 6 and 14 months. It is predicted that motivational counseling as a prelude to alcohol treatment, will significantly increase adherence to alcohol change programs and suppress maternal drinking. Project data will also be used to develop predictors of alcohol-related effects among infants, and of maternal response to intervention. Finally, the larger screened sample of 6,000 pregnancies will provide valuable epidemiological data on alcohol use and its relationship to pregnancy health complications.